The Zen of Therapy

January 6, 2022

Inside the Mind of a Buddhist Therapist: A Q&A with Mark Epstein

Mark Epstein is a psychiatrist renowned for his investigations, drawn from personal experience, into the relationship between Buddhism and psychotherapy, notably in such books as Advice Not Given, The Trauma of Everyday Life, Thoughts Without a Thinker, and Going to Pieces without Falling Apart. Now, in The Zen of Therapy: Uncovering a Hidden Kindness in Life, Epstein tackles a subject that had long intrigued him: “How does my involvement with Buddhism affect my work as a therapist? What am I offering my patients that is different from what a non-Buddhist therapist gives?”

To answer these questions, Epstein challenged himself over the course of a year to write down the details of one therapy session each week. Turning the lens back on himself, he examined his interactions with patients to see when a Buddhist element may be in play. Sometimes the influence was overt, such as when a patient asked about meditation technique. Other times it was more subtle and nuanced, a feeling: “I might find myself reaching beyond traditional analysis to help someone grasp an alternative perspective on whatever issue was troubling them.”

In The Zen of Therapy, Epstein reveals how, through his training in Western psychotherapy and decades of Buddhist study and practice, the therapeutic relationship can be a kind of spiritual friendship, a two-way meditation, that leads to greater awareness both for the patient and the psychotherapist.

Recently, John Spalding, IMS’s Director of Partnerships and Communications, spoke with Epstein about his remarkable new book.

You’ve written a lot about the intersection of meditation and psychotherapy. What’s different about this book?

My earlier books were attempts to translate meditation and the psychology of Buddhism into the psychological language we speak in the West, specifically the language that comes from Sigmund Freud. Even if we don’t believe in Freud anymore, his concepts of the ego, superego, and the instincts frame how we think about the mind, how we think about ourselves. Writing those books, I discovered that a personal voice was important, and that the more I drew from my own experiences, the more effective the books were at illuminating what I was writing about. Specifically, I tried to capture what my actual experience was, for example, during a retreat at IMS. What was happening in my mind as I walked around Gaston Pond? Or what I was thinking when, feeling very mindful at the end of a long retreat, I locked my keys in the car during a snowstorm and had to find an IMS maintenance person to help me. With those books, I found a voice that I didn’t know I had until I wrote them.

This book is still very personal, but instead of exploring what it’s like to be a meditator, it’s about what it’s like to be a therapist from inside the mind of a therapist. I had touched on this subject before but had always been reluctant to explore it deeply. In general, therapists keep what they do to themselves. But I think not discussing the therapist’s experience contributes to the mystique of the therapist, which we know is not helpful now that we’re aware of the trouble that the idealization of spiritual teachers and therapists can lead to. So, I realized there’s no reason to hide what I do if I protected my patients’ identities and they agreed to allow me to use their stories, which they did.

Speaking of IMS, those familiar with your books may know that you’ve had a long relationship with IMS, but many may not realize just how far back your ties go.

I met Joseph Goldstein, Sharon Salzberg, and Jack Kornfield, as well as Ram Dass, at Naropa’s first summer session in Boulder in 1974, a couple of years before IMS was founded. I was a psychology major at Harvard then, and Daniel Goleman, who later wrote Emotional Intelligence, was a graduate student and the section leader for a psychophysiology class I took. Danny had already been to India to study meditation, which I was very interested in, so I befriended him, and asked, “How can I learn what you know?” He said, “If you want to learn more about meditation, these friends of mine are teaching in Colorado this summer. You should go.” So, I did.

Joseph was there teaching a meditation class for Ram Dass. I took Joseph’s class, and I think Sharon was already teaching with him at that point. Jack was there teaching vipassana independently, and I took his course, too. That fall, they all started teaching together in Great Barrington, MA, where I did two two-week retreats, followed by another retreat they led in Northern California. I returned to Naropa the following summer. Danny Goleman, who by then was the adviser for my thesis on the Abhidhamma, was supposed to be there teaching a course in Buddhist psychology with Jack and Sharon. At the last minute, Danny couldn’t make it, so I took his place. I was 21 years old, teaching Buddhist psychology with Jack and Sharon, and living in the vipassana module with Joseph, Jack, Sharon, and others.

I did several more retreats with them, and the following summer I traveled with Joseph, Jack, Sharon, and 10 other people to Bodh Gaya to meet Munindra. We also went to Burma to meet Mahasi Sayadaw, and then on to Thailand to Jack’s monastery near the Laos border to meet Ajahn Chah. At the end of the summer, I returned to the states to start medical school and begin my journey to become a psychiatrist.

That’s quite a “how-I-discovered-meditation” story!

I just lucked out! But I became friends with all of them, and I saw from the very beginning how, as teachers and as people, they were just being themselves, very down-to-earth, so I didn’t idealize them in a way I might have otherwise. This gave me incredible permission just to be myself, which was in some ways the greatest gift I received from them, in addition to learning how to meditate.

Can you tell us more about the similarities between meditation and psychotherapy, from the perspective of the therapist?

When I was learning to be a therapist, I had read a few articles by Freud and his successors that explore what a therapist actually does with his or her attention during a therapy session, and their descriptions sounded very Buddhist to me. If you didn’t know what you were reading, you’d think it was Suzuki Roshi, not Freud. Statements like, “Give impartial attention to everything there is to observe.” “Don’t try to hold anything in particular in mind, but instead remain open to what’s coming from the unconscious of the patient that stimulates your own unconscious.” I was very moved by that, and I realized that I could deploy in the office what I’d learned on my retreats. And by using that kind of attention, I was summoning what the psychoanalysts call the “analytic attitude.” Unfortunately, a lot of Freud’s description of how to do that got lost over the years. It went from “evenly suspended attention,” which was Freud’s term, to “free-floating attention,” so that the emphasis became how to make an interpretation, the cognitive processing of the therapist, rather than the attentional attitude of the therapist. I think the Buddhist influence brings us back to the “therapist mind,” this sense that the therapist is imparting something important in the therapeutic process.

This brings us to the placebo effect, which you describe as an important part of therapy. Most think of the placebo effect in terms of medication and treatment. How does it work in the doctor-patient relationship?

The placebo effect is still very much a mystery, but yes—there’s something in the therapeutic relationship itself that, in some percentage of cases, promotes the healing process. How? We don’t know. To me, there’s something about the placebo effect that is redolent of mind-to-mind experience. For example, when Joseph is teaching in the meditation hall, he becomes a certain kind of Joseph Goldstein you might not encounter if you just ran into him on the street. It’s as if when Joseph gives a dharma talk, something is being transmitted, something powerful happens between him and us, that goes beyond the words he is speaking. What is that? Could we call that the placebo effect, or is it something else? Whatever we call it, teachers like Joseph, Sharon, and Jack have been using it to inspire people for 50 years.

In The Zen of Therapy, you reflect on a year’s worth of therapy sessions. Can you tell us how you organized the year according to the four seasons and four themes—clinging, mindfulness, insight, and aggression? And why aggression?

My idea was to tie each season to a stage in the progress of insight—the meditative path from clinging to compassion—as outlined in the classical texts. So, for winter, I covered clinging. For spring, mindfulness, and for summer, insight. Fall was going to be compassion. But when I showed the provisional finished copy to my editor, she pointed out that the fourth section was really about aggression, not compassion. She was right, and there’s a reason it worked out this way.

It’s our acknowledgement of anger and aggression, and our working through them, that leads to compassion. This comes from Donald Winnicott, the great British child analyst. Winnicott likens the parent-infant relationship to the therapist-patient relationship, and I extend that connection to the meditator’s relationship with his or her own mind. Winnicott’s point is that a baby’s anger isn’t differentiated from need or hunger or desire. It’s all fused into one thing. So, a parent can feel the ruthless attack of an infant in need, and that can generate in the parent a kind of anger or frustration, sometimes even hatred. Winnicott would say that the “good enough parent” is able to handle those feelings without retaliating or abandoning the child in the face of the infant’s own anger or distress. By doing so, the parent teaches the infant, this growing person, that their aggression is not totally destructive—that they, the parent, will rise above the attack. Being able to do so is an act of forgiveness, and it builds the child’s trust.

Winnicott says that patients attack their therapists in a similar way. Therapists can feel provoked and must learn how to handle their own anger. The goal is not for them to deny their anger, which would make them useless as therapists, but to hold it, and trust that they can be resilient despite their own strong feelings. The ability to do so communicates something silently to the patient that can be therapeutically healing. I love talking about this concept to Buddhist audiences because we are often afraid of our anger. We want to leapfrog over our own internal aggression rather than learn how to hold it meditatively. But when we hold our aggression mindfully, we can transform it into compassion and kindness.

What do you hope readers will take from your book?

That therapy is a lost resource. It’s a vital tool that is underutilized both in the dharma community and the larger community. By exploring the doctor-patient relationship from the perspective of the therapist, and by chronicling my own internal process during these sessions, I hope to show that the distinctions between the psychological, the emotional, and the spiritual are not as distinct as we often think, and that the therapeutic relationship can be a kind of spiritual friendship in which whatever arises is worthy of investigation. It’s really something of a miracle that therapy even exists in Western culture—you know, two people sitting in a room together with no overt agenda, just talking and waiting to see what happens, which is a very meditative act itself.

On Tuesday, January 25, 2022, at 7 PM ET, Mark Epstein will join the IMS Book Club to discuss his book The Zen of Therapy: Uncovering a Hidden Kindness in Life. Register for this free eventhere.